Success with Sumier

1
Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Please enter a valid phone number.
4
Right now, how is your health? (Weight, energy, sleep, self-confidence, stress, etc)
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Change IS possible! Why do you want to change your health? What do your dream health goals look like? (weight loss, improved sleep, improved relationships, increased activities, improved self-confidence, better fitting clothes, not being out of breath, being able to tie your shoes or walk to the mailbox or up a mountain)
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Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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Are you pregnant or nursing?
YESNO
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Are you being treated for any of the following:
Gout
High Blood Pressure
Type I Dieabetes
Type II Diabetes
Thyroid Disease
High Cholesterol
Heart complications (Afib, congestive heart failure, etc)
Other
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Rate your quality of sleep 1-10 (1=worst, 10=best)
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How many meals do you currently eat a day?
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How many snacks do you currently eat a day?
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Do you exercise? If so, how many times a week and for how long?
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How many pounds aware are you from your ideal weight (where you feel confident, healthy and in control)?
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Have you tried other weight-loss or fitness programs in the past to try to reduce your weight and improve your health?
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On a scale of 1-10, how committed are you to making changes to reach your goals?
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I have 100% confident in this program's ability to get you wherever you want to be! I have reached and maintained my health goals and want to help you do the same! I have learned that we are not overweight because of WHAT we eat alone, but we are overweight because of WHY we eat. For me to really help you, I need to understand 1) where you are 2) how you think you got here 3) and where you want to be. This is totally confidential, so please be honest. I promise that we will identify a program to help you achieve your goals. Let's do this together!
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